Provider Demographics
NPI:1003029091
Name:KELLY, SUSAN EVE (MPA,OTL)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:EVE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MPA,OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 FORT POINT RD
Mailing Address - Street 2:
Mailing Address - City:ALTON BAY
Mailing Address - State:NH
Mailing Address - Zip Code:03810-6071
Mailing Address - Country:US
Mailing Address - Phone:603-875-2523
Mailing Address - Fax:
Practice Address - Street 1:79 BLUEBERRY LA
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246
Practice Address - Country:US
Practice Address - Phone:603-524-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0887225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist